Asymmetrical temporal lobe atrophy with massive neuronal inclusions in multiple system atrophy

Journal of the Neurological Sciences 179 (2000) 50–58 www.elsevier.com / locate / jns

Asymmetrical temporal lobe atrophy with massive neuronal inclusions in multiple system atrophy Katsuhiko Shibuya

b

a,b ,

*, Hideki Nagatomo b , Kiyoshi Iwabuchi b , Masayuki Inoue c , Saburo Yagishita c , Yoji Itoh c

a Department of Neurology and Psychiatry, Numazu Central Hospital, Nakasecho 24 -1, Numazu, Shizuoka, 410 -8575 Japan Department of Neurology and Psychiatry, Kanagawa Rehabilitation Center, Nanasawa 516 Atugi, Kanagawa 243 -0121, Japan c Department of Pathology, Kanagawa Rehabilitation Center, Nanasawa 516 Atugi, Kanagawa 243 -0121, Japan

Received 11 December 1998; received in revised form 6 June 2000; accepted 3 July 2000

Abstract This report concerns a rare association of asymmetrical temporal lobe atrophy with multiple system atrophy (MSA). A 53-year-old Japanese woman developed cerebellar ataxia and parkinsonism and was diagnosed as olivopontocerebellar atrophy (OPCA). This patient showed forgetfulness and subsequent disorientation even in the early stage of the disease. She fell into a decorticate state at the age of 64, and died a year later. The autopsy showed MSA with asymmetrical atrophy of temporal lobes, intraneuronal globular inclusions mostly confined to the hippocampus, amygdaloid nucleus, and most abundant in the granule cells in the dentate fascia. These inclusions were intensely argyrophilic and expressed marked immunoreactivity to ubiquitin, but not to neurofilament (NF), tau and paired helical filaments (PHF). Ultrastructurally, they were composed of scattered short filamentous structures of 15 to 30 nm in diameter, ribosome-like granules, mitochondria and lipofuscin. The lack of immunoreactivity against tau, NF and PHF suggests that the inclusions are distinct from Pick bodies. To our knowledge, MSA in association with asymmetrical temporal lobe atrophy with the present neuronal inclusions has not been reported. This case is distinct from MSA combined with atypical Pick’s disease in the distribution and immunohistochemical properties of neuronal inclusions, and may present a new variant of MSA since the neuronal inclusions are similar, in many respects, to those of neuronal inclusions reported in MSA. Globular inclusions are also discussed in variants of Pick’s disease, amyotrophic lateral sclerosis and Alzheimer’s disease.  2000 Published by Elsevier Science B.V. Keywords: Multiple system atrophy; Globular argyrophilic neuronal bodies; Pick body; Immunohistochemistry; Ultrastructure

1. Introduction Multiple system atrophy (MSA) includes olivopontocerebellar atrophy (OPCA), striatonigral degeneration (SND) and Shy–Drager syndrome [1]. The clinicopathological unity of these syndromes is supported by the presence of characteristic argyrophilic cytoplasmic inclusions in the oligodendroglia and neurons [2–9]. Rarely, this disease may be associated with Alzheimer’s disease [10], progressive supranuclear palsy [11], or atypical Pick’s disease [12]. This study documents the case *Corresponding author. Tel.: 181-559-314-100; fax: 181-559-319221.

of a patient with MSA who displays asymmetrical temporal lobe atrophy with neuronal intracytoplasmic inclusions having some features of Pick bodies.

2. Case report A 53-year-old woman, the proprietress of ‘ryokan’ (Japanese inn) developed an unsteady gait, dysarthria, and impairment of memory. The dysmnesia gradually became worse. She often forgot the telephone number of booking visitors and was unable to continue her work as proprietress. At age 55 years, she was diagnosed as having OPCA by one of the authors (K.I.). The patient developed

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depressive state and neurogenic bladder that gradually progressed. She was admitted to Kanagawa Rehabilitation Center on June 5, 1984. On admission she looked expressionless and slightly disoriented, and showed ataxia of the arms, legs and trunk, cogwheel rigidity of both extremities, and incontinence of urine. Wechsler Adult Intelligence Scale scores were a verbal IQ of 99, performance IQ of 83 and total IQ of 93. A cranial computed tomography (CT) scan showed marked atrophy of the cerebellum and pons (Fig. 1). She became bedridden at 60 years old. Three years later, she became indifferent to daily events and her sickness. At the age of 64, she fell into a decorticated posture. She had a laughing appearance with a stiffened face when she met her daughter. She appeared euphoric. CT scans disclosed right temporal atrophy (Fig. 2). She also sometimes suffered from a urinary tract infection and phlegmon of the skin. The clinical course went gradually downhill and the patient died at age 65, 12 years after the onset of symptoms. The clinical diagnosis was mostly compatible with MSA.

sections of the cerebrum and cerebellum were embedded in paraffin wax. The routine stains employed were hemato¨ xylin-eosin, Kluver–Barrera for myelin, Holzer for glial fiber, Bodian and Bielschowsky silver impregnation, and Gallyas silver development. For electron microscopy, a small fragment of Ammon’s horn was taken from the formalin-fixed brain (postmortem delay of 6 h). The specimens were fixed in 2.5% glutaraldehyde solution, and post-fixed in 1% osmium tetroxide. After serial dehydration in graded alcohol, the samples were embedded in epon mixture. Thin sections were double-stained with uranyl acetate and lead citrate, and observed by a JEOL 2000FX electron microscope. In addition, immunohistochemistry was performed using a panel of antibodies against human tau (1:200), phosphorylated neurofilaments (NF) (200 kD) (1:120), paired helical filaments (PHF) (1:50) and ubiquitin (1:10), and an avidin–biotin–peroxidase kit. Two cases of Pick’s disease with Pick bodies were handled in the same manner and served as controls.

3. Subject and methods

4. Neuropathologic findings

The brain was fixed in 20% formalin solution for a week and the representative sections including large hemispheric

The brain weight was 920 g. Marked atrophy of the cerebellum and pons was present (Fig. 3a). On coronal sections, the putamen was atrophic and showed brown discoloration. The substantia nigra was totally depigmented. In addition, the right anterior temporal lobe and hippocampus appeared considerably atrophic, and in contrast, the left one was spared, being asymmetrical (Fig. 3b). Microscopically, the cerebellar hemispheres showed considerable loss of Purkinje cells and thinning of the granular layer with accentuation of the line of Bergmann glia. The white matter was severely demyelinated and gliotic (Fig. 3c and d). Marked neuronal loss with gliosis were seen in the olivary and pontine nuclei. There was secondary loss of the olivocerebellar and pontocerebellar fibers afferent to the cerebellum. The putamen and substantia nigra showed severe neuronal loss with extensive astrocytic proliferation (Fig. 3e). Slight pallor of the myelin with severe gliosis was seen in the anterior temporal lobe, hippocampal formation, and entorhinal area, and was much more severe on the right side. The other areas in the temporal lobes were slightly affected in a similar manner. The granule cells in the dentate fascia were decreased in number and accompanied by gliosis, the remainders of which showed globular and pale amphophilic inclusions in their cytoplasm with displacement of the nucleus (Fig. 4a). The inclusions were intensely argyrophilic and rounded on silver impregnation such as Bodian and Bielschowsky and Gallyas method (Fig. 4b). Some inclusions were shown to be doughnutshaped by diffuse staining of the perikarya, with unstained nuclei. There was a great loss of neurons and astrocytic gliosis

Fig. 1. A cranial computed tomography (CT) scan showing marked atrophy of the cerebellum and pons (September 19, 1985).

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Fig. 2. CT scans disclosing right temporal atrophy (a) and mild cerebral atrophy (b) (August 6, 1993).

in the pyramidal cell layer of Ammon’s horn and prosubiculum. The subiculum and presubiculum were spared. The remaining neurons often showed globular argyrophilic inclusions similar, but much larger, to those in the granule cells (Fig. 4c). Many similar inclusions were also seen in the amygdala, entorhinal and insular cortices, and a few in the middle and superior temporal and parietal cortices. The distribution of the neuronal loss is illustrated in Fig. 5. The inclusions were also seen in the left cerebral hemisphere but were much fewer than in the right. Primitive plaques were scattered in the cerebral cortex. Neither Lewy bodies, Pick cells (swollen neurons) nor typical Alzheimer’s neurofibrillary tangles were present anywhere. Immunohistochemically, the inclusions were immunoreactive to ubiquitin (Fig. 4d), but not to tau, NF or PHF (Table 1). In contrast, Pick bodies in two Pick’s disease expressed intense immunoreactions to tau and PHF. The histochemical properties of the inclusions are listed in Table 2. Ultrastructurally, the inclusions were recognized as globular structures that were fairly well demarcated from the other cytoplasmic structures, but had no limiting membranes. Lipofuscin, granular endoplasmic reticula and mitochon-

dria were displaced to the periphery of the cytoplasm (Fig. 6a). They consisted of scattered fibrillary structures, some mitochondria and abundant osmiophilic granules. The fibrillary structures were randomly distributed and infrequently arranged in bundles. The fibrils were 15 to 30 nm in diameter to which many osmiophilic structures were attached along the entire length (Fig. 6b). These neuronal inclusions were similar in ultrastructure to oligodendroglial argyrophilic inclusions, but they were easily differentiated by their shape and location, more Table 1 Properties of inclusions of this case Stainings Hematoxylin-eosin ¨ Kluver–Barrera Bodian Bielschowsky Gallyas–Braal

Eosinophilic Slightly blue Argyrophilic Argyrophilic Argyrophilic

Immunohistochemistry Tau PHF Neurofilament 200 kD Ubiquitin b-Amyroid Synaptophisin

Negative Negative Negative Positive Negative Negative

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Fig. 3. The brain showing marked atrophy of the cerebellum and pons (a). Coronal section of the right hemisphere. The anterior temporal lobe and ¨ ¨ hippocampus appeared atrophic (b, Kluver–Barrera). The cerebellar white matter is severely demyelinated and gliotic (c, Holzer; d, Kluver–Barrera). The substantia nigra showing severe neuronal loss with extensive astrocytic proliferation (e, HE, original magnification 3200).

easily in the granule cells of the dentate fascia. Oligodendroglial inclusions were widely distributed throughout the central nervous system as previously described [2–5].

5. Discussion In the present case, there was severe neuronal loss and

gliosis in the olivopontocerebellar system involving the cerebellar cortex, and in the striatonigral system. In addition, oligodendroglial argyrophilic inclusions [2– 4,8,9,13] were widely distributed throughout the brain. So, this case was easily diagnosed as MSA [1,14]. Interestingly, the patient developed dysmnesia and subsequent disorientation even in the early stage of the disease. The cerebrum showed asymmetrical atrophy of the

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Fig. 4. There are many globular inclusions in the granule cells in the dentate fascia on HE preparation (a). The inclusions are argyrophilic by Gallyas (b) and are immunoreactive to ubiquitin (d). The remaining neurons of Ammon’s horn often showed globular inclusions similar, but much larger, to those in the granule cells (c, HE). Original magnification: a, b, d 3400, c 3200.

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Fig. 5. Schema showing the distribution of the inclusions in the cerebral cortex (right hemisphere). Black, numerous; dark gray, many; light gray, a few.

anterior temporal lobe including Ammon’s horn, being more severe on the right side. Numerous argyrophilic inclusions were seen in the neuronal cytoplasm, and were mainly confined to the hippocampus, amygdaloid nucleus,

and entorhinal cortex where many neurons disappeared with reparative gliosis. The other cortical areas such as insular and inferior temporal cortices were also, but to a lesser extent, involved.

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Fig. 6. (a) Ultrastructurally, a neuronal inclusion shows globular filamentous structures, fairly well-demarcated from the other cytoplasmic organellae and no limiting membranes. Lipofuscin, granular endoplasmic reticula and mitochondria are displaced toward the periphery of the cytoplasm (granule cell of dentate fascia, 32000). (b) Higher magnification of Fig. 6a. The fibrillary structures are randomly distributed and infrequently arranged in bundles, measuring 15 to 30 nm.

The inclusions were intensely argyrophilic on Bodian, Bielschowsky and Gallyas stains, and immunoreactive only to ubiquitin, not to tau, phosphorylated NF or PHF. The histochemical and topographical properties of the present inclusions are summarized in Table 2, compared

with classical [15,16] and atypical Pick bodies [12], and Pick-body-like inclusions in some other diseases [17–19]. Pick bodies were immunoreactive to tau and PHF. Some Pick bodies, but not all, were immunoreactive to ubiquitin [16]. Love et al. [20] reported that most of the Pick bodies

Table 2 Neuronal cytoplasmic inclusions, immunohistochemistry, ultrastructure and distribution a Case

Typical Pick [16] Generalized variant [15] MSA1Pick [12] Alzheimer [18] ALS1Pick [19] ALS1Pick [17] Pick variant [25] Our case Our two Pick cases

Lobar

Immunohistochemistry

atrophy

Bodian

1 1 F

1 21

F,T F,T T F,T

Biel

1 1 1

Distribution

Gal

PHF

Tau

NF

Ub

Diameter

Granules

DG

HP

EC

Am

Insula

Cortex

BG

BS

11

11

11

21

Alz50(2) ANT(1)

2

21 21 21 1

15 nm 15 nm 11 nm 15–18 nm 12–16 nm 9–15 nm 12 nm 15–30 nm 15 nm

2 1 1 1 1 1 1 1 2

11 2 1 1

11 2 1

1 2 2

11 2 1

1 2 1

1 2 P

1 1 1

1 1 1

1

1 1 1

F F 1 F,P,T F,T

11 1 1 1 1 1 1

Ultrastructure

1 1

2 2 1

2 2 1

1 2 2

1

2 1 21

1 1 1

1

1

1 1 1

1 1 1

1 1

2 1 1

1 2 1 1

a Biel, Bielschowsky; Gal, Gallyas; NF, neurofilament 200 kD; Ub, ubiquitin; DG, dentate granular cell layer; HP, hippocampal pyramidal cell layer; EC, entorhinal cortex; Am, amygdala; BG, basal ganglia; BS, brain stem nucleus; F, frontal cortex; P, parietal cortex; T, temporal cortex.

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were positive to ubiquitin. Thus, the present neuronal inclusions were superficially similar to but apparently distinct from Pick bodies. Neuronal cytoplasmic inclusions (NCIs) in MSA were positive for ubiquitin and occasionally positive for neurofilament, while negative for tau and PHF [21]. Therefore, the present inclusions are very similar, in their stainability, to the neuronal inclusions reported in MSA [21], but their distribution is quite different since the latter are mainly confined to the pontine neurons in their cases. The inclusions in a case of MSA reported by Horoupian and Dickson [12] were also different in distribution form. Ultrastructurally, the present inclusions were composed of scattered short fibrillary structures of 15 to 30 nm in diameter to which many osmiophilic granules were attached along the entire length of the fibrils. In contrast, the inclusions of classical Pick disease [15,16] consisted of straight filaments [22,23], paired twisted profiles [16] or periodically constricted filaments or NF with a geometrical pattern [22,24]. Thus, the inclusions of the present case are distinct from that of classical Pick disease. Munoz-Garcia et al. [15] described generalized variants of Pick’s disease in which the bodies consisted of straight fibrils coated with granular material. The bodies were composed primarily of skeins of neurofilaments studded with granular substances [25]. Pick-body-like inclusions in motor neuron disease consisted of fibrils decorated by granular and fuzzy materials along their entire length [17,19]. Neuronal cytoplasmic inclusions (NCIs) in MSA also consisted of fibrils with granular materials [21,26]. The inclusions of generalized variants of Pick’s disease, motor neuron disease with dementia and NCIs in MSA resemble each other in the components of fibrillary structures with granular substances, and are also similar in some respects to the inclusions of the present case. The inclusions in MSA with atypical Pick disease reported by Horoupian and Dickson [12] were formed from the skeins of straight intermediate filaments with a smooth surface. They are different from the inclusions of the present case. This case had some features of generalized variant of Pick’s disease, but the present inclusions in this case were found mostly in the hippocampus. The inclusions in generalized variant of Pick’s disease [15] are absent or rare in this region. Interestingly, the present neuronal inclusions were virtually identical, in ultrastructure as well as in their immunohistochemical stainability, to oligodendroglial inclusions in MSA [2,5,27]. Thus, pathological changes might develop in neurons and oligodendroglial cells in the same mechanism. So this case may be a new variant of MSA and not a mere co-existence of Pick’s disease or its variant.

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